Inspection Reports for
Veterans Community Living Center at Fitzsimons
CO, 80045
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
79% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 21, 2024
Visit Reason
The inspection was conducted due to allegations of resident-to-resident physical and sexual abuse involving multiple residents, including incidents on 5/29/24, 9/16/24, and 11/17/24.
Complaint Details
The complaint investigation substantiated physical abuse between Residents #60 and #127 on 11/17/24 and sexual abuse by Resident #92 against Resident #45 on 5/29/24 and 9/16/24. The facility's internal investigations included interviews, record reviews, and staff statements. The sexual abuse was substantiated, but no documentation was found regarding substantiation status for the physical abuse. The facility implemented 15-minute checks and moved Resident #92 to a different unit after the incidents.
Findings
The facility failed to prevent resident-to-resident physical and sexual abuse involving four residents out of five reviewed. The investigation substantiated physical abuse between Residents #60 and #127 and sexual abuse by Resident #92 against Resident #45 on two occasions. The facility lacked timely and effective interventions to protect residents at risk and failed to update assessments after cognitive decline was noted.
Deficiencies (4)
Failed to prevent resident-to-resident physical abuse between Resident #127 and Resident #60, who had a known history of aggressive behaviors.
Failed to have timely effective interventions to protect Resident #127 from physical aggression and wandering into other residents' rooms.
Failed to prevent resident-to-resident sexual abuse of Resident #45 by Resident #92 on 5/29/24 and 9/16/24.
Failed to complete an updated assessment for Resident #92 after noted cognitive decline due to dementia.
Report Facts
Residents reviewed for abuse: 45
Residents affected: 4
Frequency of behavior monitoring: 15
Dates of sexual abuse incidents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA | Nursing Home Administrator | Provided facility policy, interviewed regarding incidents and facility response |
| CNA #6 | Certified Nurse Aide | Interviewed about resident interactions and altercation on 11/17/24 |
| LPN #1 | Licensed Practical Nurse | Interviewed about resident behaviors and interventions |
| SSD | Social Services Director | Interviewed regarding sexual abuse incidents and resident interactions |
| SSA | Social Services Assistant | Interviewed regarding sexual abuse incidents and resident interactions |
| DSW | Divisional Social Worker | Interviewed about resident relationships and cognitive status |
Inspection Report
Routine
Deficiencies: 8
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, abuse prevention, care planning, dental care, infection control, and other standards.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, prevent resident-to-resident abuse and sexual abuse, revise comprehensive care plans timely, provide appropriate wound care and skin treatment, assist residents with dental care needs, accommodate resident food preferences, provide appropriate range of motion treatments, and maintain an effective infection prevention and control program including water management and proper wound care instrument sanitation.
Deficiencies (8)
Failed to ensure call light was within reach for Resident #65 with limited range of motion, impacting dignity and timely assistance.
Failed to prevent resident-to-resident physical and sexual abuse involving Residents #127, #60, #45, and #92, including inadequate interventions and monitoring.
Failed to revise and review comprehensive care plans for five residents (#122, #104, #81, #46, #65) to reflect medication use and skin treatment.
Failed to ensure timely reporting and appropriate treatment of new skin alterations for Resident #65, including delayed notification and incomplete care plan updates.
Failed to provide appropriate range of motion treatment for Resident #45, including failure to follow physician's order for exercise bike use.
Failed to assist residents (#81, #45, #93) in obtaining timely routine or emergency dental care, including failure to schedule dental appointments and follow up on dental pain complaints.
Failed to provide food that accommodated Resident #10's preferences, including failure to offer Mexican food and hot sauce as documented in care plan and meal ticket.
Failed to maintain an infection prevention and control program, including inadequate water management program lacking detailed building water system description and monitoring, and improper sanitation of wound care scissors.
Report Facts
Residents reviewed: 45
Residents affected by dignity deficiency: 1
Residents affected by abuse deficiency: 4
Residents with care plan deficiencies: 5
Residents with dental care deficiencies: 3
Residents with food preference deficiency: 1
Residents with wound care deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Interviewed regarding call light placement for Resident #65 and wound care practices |
| CNA #1 | Certified Nurse Aide | Interviewed regarding call light placement responsibilities |
| CNA #2 | Certified Nurse Aide | Interviewed regarding call light placement and skin condition reporting for Resident #65 |
| Assistant Director of Nursing | ADON | Interviewed regarding call light policies, care plan responsibilities, and skin care monitoring |
| Unit Manager | UM | Interviewed regarding wound care responsibilities and infection control practices |
| Social Services Director | SSD | Interviewed regarding abuse investigations, dental care scheduling, and resident interactions |
| Social Services Assistant | SSA | Interviewed regarding abuse investigations and dental care scheduling |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding resident aggression and monitoring |
| Certified Nurse Aide #6 | CNA | Interviewed regarding resident interactions and monitoring |
| Nursing Home Administrator | NHA | Interviewed regarding abuse investigations, legionella policy, and resident safety |
| Physical Therapist | PT | Interviewed regarding exercise bike use and resident therapy plans |
| Restorative Manager | RM | Interviewed regarding therapy programs and resident participation |
| Registered Dietitian | RD | Interviewed regarding resident nutritional risk and food preferences |
| Dietary Manager | DM | Interviewed regarding meal preparation and resident food preferences |
| RN #1 | Registered Nurse | Interviewed regarding wound care and skin assessments |
| RN #2 | Registered Nurse | Observed and interviewed regarding wound care and instrument sanitation |
| SW #1 | Social Worker | Interviewed regarding dental care scheduling and resident pain |
Inspection Report
Deficiencies: 7
Date: Jun 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, trauma-informed care, hydration, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate care for residents with limited range of motion, failure to prevent elopement of a high-risk resident, failure to provide trauma-informed care for residents with PTSD, failure to prevent unnecessary medication use including excessive acetaminophen dosing and antidepressant use without proper assessment and consent, failure to ensure adequate hydration for a resident, and failure to implement effective quality assurance and performance improvement processes.
Deficiencies (7)
Failure to provide appropriate care for Resident #28 with limited range of motion and bilateral hand contractures.
Failure to ensure Resident #106, at high risk of elopement, was kept safe leading to two elopement incidents.
Failure to provide trauma-informed care and conduct trauma assessments for eight residents with PTSD or trauma history.
Failure to prevent excessive acetaminophen dosing for Resident #83 exceeding recommended daily limits.
Failure to assess Resident #58 for depression prior to ordering and administering antidepressant medication at family request without resident consent.
Failure to ensure Resident #90 was offered sufficient hydration and water pitchers were kept within reach.
Failure of the quality assurance performance improvement (QAPI) program to identify and address elopement risks and security failures leading to immediate jeopardy.
Report Facts
Residents sampled: 53
Acetaminophen daily dose: 3575
Acetaminophen excess dose: 575
Resident #90 hydration deficit: 450
Resident #90 hydration deficit: 120
PHQ-9 depression score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Noted excessive acetaminophen dosing for Resident #83 and planned to notify physician |
| RPH | Registered Pharmacist | Confirmed excessive acetaminophen dosing for Resident #83 |
| NHA | Nursing Home Administrator | Discussed failures in elopement prevention and QAPI committee deficiencies |
| DON | Director of Nursing | Interviewed regarding elopement, hydration, and antidepressant medication consent and assessment |
| SSD | Social Services Director | Discussed lack of trauma assessments and antidepressant medication consent issues |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Feb 27, 2023
Visit Reason
The inspection was conducted due to complaints and allegations regarding resident abuse, failure to provide CPR as ordered, inadequate dementia care, failure to assess and notify physician of change in condition, and failure to maintain an effective quality assurance program.
Complaint Details
The complaint investigation revealed substantiated findings of resident to resident abuse, failure to provide CPR as ordered for two residents who died, failure to assess and notify physician of change in condition for one resident, inadequate dementia care for two residents, failure to update facility assessment, and failure to maintain an effective quality assurance program.
Findings
The facility failed to protect residents from abuse and neglect, failed to provide CPR as ordered for residents in cardiac arrest, failed to assess and notify physicians of changes in resident conditions, failed to provide adequate dementia care and activities, and failed to maintain an effective quality assurance program. Multiple residents were involved in altercations, and staff failed to provide required supervision and interventions. The facility also failed to update its comprehensive facility assessment and to conduct effective quality assurance activities.
Deficiencies (6)
Failure to protect residents from abuse and neglect, including resident to resident physical altercations and inadequate supervision.
Failure to provide basic life support including CPR to residents with orders for resuscitation, resulting in immediate jeopardy.
Failure to assess and notify physician of change in condition for a resident with irregular vital signs.
Failure to provide appropriate dementia care including person-centered care plans, interventions, and meaningful activities.
Failure to conduct and document a comprehensive facility-wide assessment to determine resources necessary to care for residents competently.
Failure to maintain an effective quality assurance and performance improvement program to identify and address facility compliance concerns.
Report Facts
Residents reviewed for abuse: 17
Residents on secured unit: 14
One-to-one monitoring start date: Resident #1 placed on one-to-one monitoring on 12/21/22.
BIMS score Resident #1: 4
BIMS score Resident #2: 3
Blood pressure Resident #3: 171
Pulse Resident #3: 90
Respirations Resident #3: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in failure to provide CPR to Resident #3. |
| RN #2 | Registered Nurse Supervisor | Named in failure to provide CPR to Residents #3 and #4. |
| LPN #3 | Licensed Practical Nurse | Named in failure to provide CPR to Resident #4. |
| Social Services Director | Conducted investigation into resident altercation and abuse. | |
| Director of Clinical Operations | Provided facility policies and interviewed regarding supervision and CPR. | |
| Nursing Home Administrator | Interviewed regarding facility assessment, QAPI, and corrective actions. | |
| Activities Director #1 | Interviewed regarding activities for residents with dementia. | |
| AA #2 | Interviewed regarding secured unit activities and resident preferences. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 20, 2020
Visit Reason
The inspection was conducted based on complaints regarding resident care, including the use of restraints for discipline or convenience, failure to provide appropriate activities for residents with dementia, and inadequate communication and coordination of dialysis care.
Complaint Details
The complaint investigation focused on allegations that the facility used restraint for discipline by removing a resident's powered wheelchair, failed to provide appropriate activities for a resident with dementia, and did not maintain proper communication with the dialysis center for a resident receiving dialysis.
Findings
The facility failed to prevent the use of restraint as discipline by taking away Resident #70's powered wheelchair, causing emotional harm. It also failed to provide person-centered activities for Resident #88 with advanced dementia, and failed to establish proper communication and agreements with the dialysis center for Resident #106, resulting in incomplete dialysis communication forms and lack of coordination.
Deficiencies (3)
Failed to prevent use of restraint for discipline by taking Resident #70's powered wheelchair away, causing humiliation and depression.
Failed to provide person-centered activities that met the interests and needs of Resident #88 with advanced dementia.
Failed to establish and maintain communication and agreement with dialysis center for Resident #106, resulting in incomplete dialysis communication forms and lack of coordination.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #11 | Restorative Nurse | Interviewed regarding PPV use and disciplinary removal of powered wheelchair |
| Social Services Director | Social Services Director | Interviewed regarding PPV policy and resident mobility |
| Director of Physical Therapy | Director of Physical Therapy | Interviewed regarding PPV assessment and safety |
| MDS Coordinator | MDS Coordinator | Interviewed regarding resident behavior and PPV removal |
| CNA #5 | Certified Nurse Aide | Interviewed regarding activities provided to Resident #88 |
| CNA #2 | Certified Nurse Aide | Interviewed regarding Resident #88's participation in activities |
| RTA #4 | Recreational Therapy Aide | Interviewed regarding activities programming and Resident #88 |
| Recreational Therapy Director | Recreational Therapy Director | Interviewed regarding Resident #88's activity needs |
| RTA #5 | Recreational Therapy Aide | Interviewed regarding sensory activities for Resident #88 |
| DON | Director of Nursing | Interviewed regarding activities and dialysis communication |
| NHA | Nursing Home Administrator | Interviewed regarding dialysis agreement and communication |
| RN #9 | Registered Nurse | Interviewed regarding dialysis communication form completion |
| RN #3 | Registered Nurse | Interviewed regarding dialysis communication form responsibilities |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding dialysis communication form and resident care |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding dialysis communication form completion |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding dialysis communication form and follow-up |
Viewing
Loading inspection reports...
